Review Article | Thoracic Imaging

https://doi.org/10.3348/kjr.2018.19.5.866
pISSN 1229-6929 · eISSN 2005-8330
Korean J Radiol 2018;19(5):866-871

2018 Korean Clinical Imaging Guideline for Hemoptysis

Mi-Jin Kang, MD1, Jin Hwan Kim, MD, PhD2, Yoon Kyung Kim, MD, PhD3, Hyun Joo Lee, MD4,
Kyung Min Shin, MD5, Jung Im Kim, MD, PhD6, Hyun Ju Lee, MD, PhD7, Kyung Hyun Do, MD, PhD4,
Hwan Seok Yong, MD, PhD8, Sol Ji Choi, PhD9, Miyoung Choi, RN, MPH, PhD9, Jung Im Jung, MD, PhD10
1
Department of Radiolgoy, InJe University Sanggye Paik Hospital, Seoul 01757, Korea; 2Department of Radiology, Chungnam National University
Hospital, Chungnam National University School of Medicine, Daejeon 35015, Korea; 3Department of Radiology, Gachon University Gil Hospital,
Incheon 21565, Korea; 4Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical
Center, Seoul 05505, Korea; 5Department of Radiology, Kyungpook National University Medical Center, Daegu 41944, Korea; 6Department of
Radiology, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul 05278, Korea; 7Department of Radiology,
Seoul National University Hospital, Seoul 03080, Korea; 8Department of Radiology, Korea University Guro Hospital, Korea University College of
Medicine, Seoul 08308, Korea; 9Division for Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating
Agency, Seoul 04554, Korea; 10Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul
06591, Korea

In 2014, the American College of Radiology (ACR) announced the guideline for the appropriate diagnostic approach and
treatment of patients according to the severity of hemoptysis and risk for lung cancer. However, the application of the ACR
guideline in Korea may not be appropriate, because many patients in Korea have active tuberculosis or pulmonary fibrosis
due to previous tuberculosis. The Korean Society of Radiology and Korean Society of Thoracic Radiology have proposed a
new guideline suitable for Korean practice. This new guideline was prepared through the consensus of a development
committee, working party, and an advisory committee. The guideline proposal process was based on an evidence-based
clinical imaging guideline proposed by the development committee. Clinical imaging guideline for adult patients with
hemoptysis is as follows: Chest radiography is an initial imaging modality to evaluate hemoptysis. Contrast-enhanced chest
CT is recommended in patients with two risk factors for lung cancer (> 40 years old and > 30 pack-year smoking history),
moderate hemoptysis (> 30 mL/24 hours) or recurrent hemoptysis. Contrast-enhanced chest CT is also recommended in
patients with massive hemoptysis (> 400 mL/24 hours) without cardiopulmonary compromise.
Keywords: Guideline; Hemoptysis; Thorax; Lung; Radiography; X-ray; Computed tomography; Evidence; Republic of Korea

Received February 22, 2018; accepted after revision April 3, 2018.

This study was supported by the National Evidence-based Collaborating Agency (NECA-C-15-003) and the Korean Society of Radiology
(NECA-S-15-002).
This Guideline has been published jointly by invitation and consent in both the Journal of the Korean Society of Radiology (in Korean)
and the Korean Journal of Radiology (in English).
Corresponding author: Jung Im Jung, MD, PhD, Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic
University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea.
• Tel: (822) 2258-1435 • Fax: (822) 599-6771 • E-mail: jijung@catholic.ac.kr
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://
creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium,
provided the original work is properly cited.

866 Copyright © 2018 The Korean Society of Radiology

Clinical Imaging Guideline for Hemoptysis

Background of the Development of the Korean
Clinical Imaging Guideline
Hemoptysis is the expectoration of blood to mouth or
nose that originates from the respiratory tract. Clinical
management is different according to the severity of
hemoptysis based on the volume of blood loss. However,
retained blood in lung parenchyma can be underestimated
due to the difficulty in determining the exact volume of
blood loss in routine practice. Diagnostic imaging is salient
for appropriate diagnosis and treatment because hemoptysis
can originate from various diseases such as acute benign
disease (including bronchitis), chronic benign disease
(including bronchiectasis), or malignant tumor.
A clinical imaging guideline for hemoptysis has been
previously published by the American College of Radiology
(ACR) (1). ACR guideline states diagnostic and treatment
strategies according to the severity of hemoptysis and risk
factor for lung cancer. The ACR emphasized the importance
of undiagnosed lung cancer in hemoptysis patients.
However, there is a need for a guideline specific to
Korea, because it is an endemic tuberculosis area with a
high rate of hemoptysis patients with pulmonary fibrosis
caused by previous tuberculosis or hemoptysis from active
tuberculosis. Consequently, the development committee,
working party, and an advisory committee have developed a
guideline suitable for Korean practice.
Adaptation Process of the Guidelines
The guideline development process was based on a
guideline adaptation methodology process suggested by the
development committee (2).
Key Questions
The key questions made by working group were reviewed
and revised by the development committee and consensus
group. The consensus group represented the suggested
end user and was selected from The Korean Academy of
Tuberculosis and Respiratory Disease. The finalized key
question is in a structured form below.
1. What is the most appropriate imaging test to
diagnose the cause of hemoptysis in an adult patient with
hemoptysis?
Search Guidelines
The development committee searched for guidelines
using international databases (Ovid-MEDLINE and Ovid-

Records identified through international database searching Records identified through domestic database searching
Ovid-MEDLINE (n = 4) KoreaMed (n = 4)
Ovid-EMBASE (n = 13) KMBASE (n = 1)
NGC (n = 9) KGC (n = 9)
GIN (n = 6) KoMGI (n = 0)
Trip OR Google (n = 0) Searched guideline through manual method (n = 1)
(Total n = 32) (Total n = 15)

Records after duplication removed

Records excluded by abstract screening
(domestic n = 15/international n = 32)
(Total n = 26)
(Total n = 47)

Full-text guidelines assessed for eligibility
(domestic n = 0/international n = 21)
(Total n = 21)
Guidelines included for KCIG
(domestic n = 0/international n = 1)
(Total n = 1)
Records excluded according to exclusion criteria (n = 20)
1. Patients of hemoptysis are not included (n = 10)
2. Guidelines not related to hemoptysis (n = 8)
3. Appropriate results were not reported (n = 1)
4. Recommendations were not suggested (n = 0)
5. Guidelines not reported in English or Korean (n = 1)
6. Overlapping publication (n = 0)
7. Full-text was not obtainable (n = 0)

Fig. 1. Flow chart for literature selection. GIN = Guideline International Network, KCIG = Korean Clinical Imaging Guidelines, KGC = Korean
Guideline Clearinghouse, KoMGI = Korean Medical Guidelines and Information, NGC = National Guideline Clearinghouse

kjronline.org Korean J Radiol 19(5), Sep/Oct 2018 867

 Kang et al.

Table 1. AGREE II
Source of Recommendation AGREE II Score Proposal of Developmental Committee
ACR Appropriateness Criteria® hemoptysis 66 Recommended
Not recommended: AGREE score < 50. ACR = American College of Radiology, AGREE II = Appraisal of Guidelines for Research & Evaluation II

Table 2. Criteria for Evidence Level of Each Evidence Literature

Level Content
Research satisfying all of criteria following three
1) Good reference standard
2) Consecutive patients study
1
3) Blind interpretation
Systematic review of level 1
Randomized controlled trial or cross-sectional cohort study that compares index test to comparators
Research satisfying all of criteria following two
1) Good reference standard
2 2) Consecutive patients study or blind interpretation
Systematic review of level 2
Observational studies that compares index test to comparators
3 Without consistently applied reference standards
Case-control study
4
Poor or non-independent reference standard
5 Expert opinion
Adapted from Choi et al. Korean J Radiol 2017;18:208-216 (2)

Table 3. Grades of Korean Clinical Imaging Guideline Recommendation

Grading Content Meaning
This intervention (examination) has enough evidence to support desired effect, and therefore, is
A Recommended
recommended
(Conditional) This intervention (examination) has intermediate to enough level of evidence to support desired effect
B
recommended Provide intervention (examination) selectively, or for specific individuals based on expert’s judgment
This intervention (examination) has enough evidence to support non-desired effect, and therefore, is not
C Not recommended
recommended (use of this examination is not recommended)
This intervention (examination) does not have enough evidence to either support or reject effectiveness,
and needs further research
I No recommendation
This intervention (examination) has very low level of certainty for desired effect, and decision based on
recommendation grading has no meaning
Adapted from Choi et al. Korean J Radiol 2017;18:208-216 (2)

EMBASE), several international sites associated with
guidelines (National Guideline Clearinghouse and Guideline
International Network) and major domestic databases
(KoreaMed, KMbase, Korean Medical Guidelines and
Information, and Korean Guideline Clearinghouse).
In addition, the websites of major academic societies
and institutions were also searched along with a manual
database search. We performed literature searches
from 2000 to July, 2015 for the keywords hemoptysis,
computerized tomography, or bronchoscopy, using Medical
Subject Heading (MeSH) terms or Embase subject headings
(EMTREE). Guidelines or articles published after that period
were included by an up-to-dated search.
Selection of Searched Guidelines
A total of 47 guidelines were searched: 32 guidelines
in an international database, 14 guidelines in a domestic
database, and 1 guideline by a manual search. In the
primary screening process, 21 records were selected after
reviewing the title and abstract of an identified study or
guideline. One guideline was selected after the full-texts
of identified literature were reviewed in the secondary
screening process that also noted the reason for the
exclusion of any specific literature selected (Fig 1).

868 Korean J Radiol 19(5), Sep/Oct 2018 kjronline.org

Clinical Imaging Guideline for Hemoptysis
Quality Appraisal of the Guidelines
The final selected guidelines underwent quality appraisal
using the Korean Appraisal of Guidelines for Research
& Evaluation II (AGREE II) tool of the development
committee. Final appraisal results were provided to the
working group (Table 1). The working group selected one
guideline for the key question in consideration of the
quality of the selected guideline.
Grading the Level of Evidence and Drafting the
Recommendation Document
Working group members reviewed evidence in the
literature that supported the final selected guideline
recommendations. Grading the level of evidence for each
literature was performed to create an evidence table
(Supplementary Table 1 in the online-only Data Supplement)
according to the evidence level criteria of the Korean
Clinical Imaging Guidelines (K-CIG) (Tables 2, 3). The draft
version of the recommendation document was based on
the prepared evidence table after a final discussion of the
working group.
Agreement of the Recommendation Grades
The draft version of the recommendation document
prepared by the working group was reviewed and discussed
by the development committee. The final level of evidence
and grade of recommendation was determined by the
consensus of the development committee and working
group, according to K-CIG criteria (2).
Finalizing the Recommendation Document
The Delphi method was used for formal consensus. The
consensus group was composed of clinical imaging experts,
end-users from the clinical imaging guideline-related
academic societies (The Korean Academy of Tuberculosis and
Respiratory Disease), and research methodology experts.
The results of the Delphi were as follows: degree of
agreement on primary survey was 7.3−8.6 (standard
deviation: 0.5−0.9) and degree of agreement on secondary
survey 6.9−8.5 (standard deviation: 0.5−0.8).
External Review and Approval of Clinical Guideline
Clinical experts related to the area of the
recommendations, such as members from The Korean
Academy of Tuberculosis and Respiratory Disease reviewed
the final recommendations. Feedback and modification was
subsequently reflected in the documents.
kjronline.org Korean J Radiol 19(5), Sep/Oct 2018
Recommendations
Key Question
1. What is the most appropriate imaging test to
diagnose the cause of hemoptysis in an adult patient with
hemoptysis?
[Recommendation 1-1]
Chest radiography is suggested for initial evaluation in all
adult patients with hemoptysis.
(recommendation grade A, evidence level II)
[Recommendation 1-2]
Contrast-enhanced chest CT scan is recommended to
diagnose the cause of hemoptysis in all adult patients with
hemoptysis and who have two risk factors for lung cancer (>
40 years old and > 30 pack-year smoking history).
(recommendation grade A, evidence level II)
[Recommendation 1-3]
Contrast-enhanced chest CT scan is recommended to
diagnose the cause of hemoptysis in all adult patients
with moderate hemoptysis (> 30 mL/24 hours) or recurrent
hemoptysis.
(recommendation grade A, evidence level II)
[Recommendation 1-4]
Contrast-enhanced chest CT scan should also be
considered in adult patients with massive hemoptysis (>
400 mL/24 hours) and preserved cardiopulmonary function.
(recommendation grade A, evidence level III)
Evidence Summary
Hemoptysis is spitting blood from the respiratory tract
due to various causes that range from blood tinged sputum
to massive hemoptysis. Causes of hemoptysis include benign
disease such as bronchiectasis, acute bronchitis, chronic
bronchitis, tuberculosis, diffuse interstitial lung disease,
and pulmonary venous malformation or malignant disease
such as lung cancer and idiopathic. Therefore, appropriate
screening test and complete medical examinations are
required (3-5). This paper proposes a clinical imaging
guideline for adult patients with hemoptysis.
The guideline recommends chest radiography as an
initial evaluation for all adult hemoptysis patients. Chest
radiography can help lateralize the bleeding site and screen
for the presence or absence of abnormality in the pleura
869

and lung parenchyma (3, 6, 7).
Clinical imaging guidelines differ according to the amount
of hemoptysis: minor (< 30 mL/24 hours), moderate (30−400
mL/24 hours), or massive hemoptysis (> 400 mL/24 hours)
(7-10).
Contrast-enhanced chest CT scan is recommended to
exclude the possibility of lung cancer in patients with
hemoptysis and normal chest radiographs, if the patient
has two risk factors for malignancy (> 40 years old and
> 30 pack-year smoking history). In adult patients with
hemoptysis, the incidence of malignancy was reported as
10−35% (2, 3). In a report on the long-term outcome and
incidence of lung cancer in patients with hemoptysis of
unknown origin, unresectable lung cancer developed in 6%
of patients within 3 years after the first presentation; all
patients were smokers and > 40 years old (11). In another
retrospective study of patients with hemoptysis and normal
radiography, 9.6% of patients were diagnosed with lung
cancer; all patients were current or ex-smokers (12).
The accurate assessment of the cause is more important
than prompt treatment in patients with moderate
hemoptysis (> 30 mL/24 hours) or recurrent hemoptysis.
Previous reports indicate that the most common cause
of hemoptysis in Korea was bronchiectasis, followed by
active tuberculosis, and tuberculosis sequelae (5). Possible
remaining causes were pneumonia, aspergilloma, lung
cancer, others, or unknown (5). CT is more useful than
bronchoscopy, because it is noninvasive and accurately
assesses the cause and site of hemoptysis; in addition, it
is also possible to diagnose bronchiectasis, tuberculosis
and lung cancer with non-contrast-enhanced CT. However,
contrast-enhanced CT is recommended to accurately
assess the bleeding site, because non-bronchial collateral
arteries could be the source of bleeding in tuberculosis
patients despite the bronchial artery being the common
source of bleeding (13-15). Inoperable massive hemoptysis
was considered a major indication of bronchial artery
Table 4. Korean Relative Radiation Level
Symbol RRL (mSv)
0 0
<1
1−5
> 5−10
> 10
CT = computed (computer) tomography, CTA = computed tomography angiography, IVU = intravenous urography, MRI = magnetic
resonance imaging, RRL = relative radiation level, PA view = posteroanterior view, UGIS = upper gastrointestinal series. Adapted from
Choi et al. Korean J Radiol 2017;18:208-216 (2).
870
Kang et al.
embolization; however, moderate hemoptysis or mild but
chronic and worsening hemoptysis is also considered an
indication of bronchial artery embolization (14). Contrast-
enhanced CT can guide bronchial artery embolization and
reduce procedure time, because it adequately depicts the
imaging anatomy of the bronchial artery and non-bronchial
collateral arteries (intercostal artery, subclavian artery,
axillary artery, and inferior phrenic artery), pulmonary
artery and pulmonary vein (16).
A contrast-enhanced CT scan is recommended for patients
with massive hemoptysis (> 400 mL/24 hours) who preserve
cardiopulmonary function. Massive hemoptysis can be
treated by bronchial artery embolization or surgery; in
addition, CT prior to these treatments can be helpful to
detect the causative vessel (7, 17).
Consideration for Recommendation
Benefit and Harm
Performing chest radiography as a screening test in
patients with hemoptysis is useful in terms of low radiation
exposure, lateralization of bleeding site, and as a screening
test for lung disease.
Regardless of the amount of hemoptysis, chest CT is
recommended in patients who have two risk factors for
malignancy (> 40 years old and > 30 pack-year smoking
history). Chest CT has the benefit to detect hidden lung
cancer that cannot be detected on chest radiography;
however, caution is advised due to radiation exposure.
CT is very useful for the simultaneous detection of
the bleeding site and cause of bleeding in patients with
moderate hemoptysis (> 30 mL/24 hours) or recurrent
hemoptysis. In Korea, hemoptysis is commonly associated
with inflammatory diseases that include active tuberculosis
and tuberculosis sequelae. In these cases, chest radiography
has several limitations in the evaluation of the bleeding
site. CT is therefore very useful for the exact evaluation of
Example
Sonography, MRI
Chest radiography (PA view), mammography
IVU, UGIS, low-dose chest CT, brain CT, brain CTA
Routine chest CT, abdominal CT, coronary CT
3-phase dynamic CT (abdomen)
Korean J Radiol 19(5), Sep/Oct 2018 kjronline.org
Clinical Imaging Guideline for Hemoptysis
bleeding size and causative disease.
Bronchial artery embolization is considered a treatment
option in patients with massive hemoptysis, moderate
hemoptysis, or recurrent hemoptysis. CT performed before
embolization shows a detailed anatomy of both the
bronchial artery and pulmonary artery, helps guide the
procedure, and can reduce the procedure time. CT before
embolization has significant benefits that outweigh
radiation hazards.
Contrast-enhanced CT could have hazards related to the
iodine contrast media. We should follow the consultation
guide for contrast media that indicates the benefits of
contrast media versus the harm from iodine before choosing
to use contrast media.
Radiation Dose
Relative radiation level of chest radiography is less than
1 mSv and that of chest CT is 5−10 mSv (Table 4).
Supplementary Materials
The online-only Data Supplement is available with this
article at https://doi.org/10.3348/kjr.2018.19.5.866.
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